Spencer Johnson, M. D., wrote a short fable with this title about the way people respond to change.[i] One of its main points is that change will come, but if you wait too long to act, either because of fear or “paralysis by analysis,” you won’t make it. So what sorts of change are we facing? While we can all come up with a list, there is one change I want to highlight here.

Traditionally, and still in law, everything happens in a hospital as a result of a physician’s order. Said in different language, everything in the hospital has been organized on the “opt in” principle. However, the best way to make care more reliable is to decide in advance what “ought” to happen, and set it up to make sure it does happen. In other words, we have to move to an “opt out” principle. I hear physicians say that this is “cookbook” medicine, which implies that following a recipe is inferior to making it up as you go. Those of you who watch the cooking shows on the Food Network know that when you are baking a cake, success is dependent upon having a precise ratio of the ingredients to create the property chemistry. If you don’t, your effort will flop.

Now I don’t want to imply that practicing medicine has gotten to the point where you can “just follow the recipe.” On the other hand, I do think it is not only possible, but actually desirable to build care processes using the “recipe” that represents our best understanding of the evidence. I care for a large number of patients undergoing outpatient hemodialysis. While each patient is an individual, our goal is always the same: to deliver “adequate” dialysis asymptomatically and cost effectively. Standardizing the measurements we use, and standardizing the processes needed to achieve success required writing many “standing orders” and protocols. Each of these represented my best thinking about the issue at the time they were written, but they can be changed when the evidence shows there is a better way. I can “opt out” to stop a protocol, so I can deal with those things that make the protocol inappropriate. As a result, my patients do better than the national average in terms of both survival and hospitalization, and I get to sleep with fewer interruptions.

Does “opting out” diminish your importance as a physician? Since I think we get paid the “big bucks” for making the hard decisions, I think an “opt out” system makes our work even more important, since we have to work with our patients and their families to make decisions about what sort of care is appropriate for that particular patient. If there is a reason why “standard care” is not appropriate, then we should say so in the chart, and write a different set of orders. Has our “cheese” moved? You bet. But I think the “cheese” to be had with an “opt out” system is vastly better than the stale old cheese of the “opt in” system. What do you think? Are you willing to give it a try?